Letter to the editor
Med Ultrason 2016, Vol. 18, no. 3, 403-409
Management and outcome of sonographically diagnosed uterine enhanced myometrial vascularity / arteriovenous malformations following early pregnancy events: a single center experience Jennifer K.Y. Ko, Vincent Y.T. Cheung Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong
To the Editor, Uterine enhanced myometrial vascularity (EMV), also known as arteriovenous malformations (AVM), is rare, usually acquired and developed following a pregnancy event.EMV is the term used recently to describe acquired AVM regardless of the presence or absence of products of gestation [1]. Some authors collectively name acquired vascular structures of the uterus identified by color Doppler as EVM/AVM [1]. The clinical significance of this finding and its management particularly in asymptomatic women is not well established. In the current series, we reviewed our experience on a group of women who had EMV/AVM diagnosed with color Doppler ultrasound after an early pregnancy event. This review had obtained ethical approval from the Institutional Review Board. Between January 2010 and December 2013, EMV/ AVM was diagnosed in 22women with transvaginal Doppler ultrasound. Nine women (41.0%) were asymptomatic at the time of diagnosis. Reasons for ultrasound examination included abnormal uterine bleeding in 12 women (54.5%), reassessment after miscarriages in 9 women (41.0%), and abdominal pain after surgical abortion in 1 woman (4.5%).The typical finding on color Doppler ultrasound was atangle of tortuous vessels with multidirectional, high-velocity and turbulent flow (fig 1). The Received 18.04.2016 Accepted 22.04.2016 Med Ultrason 2016, Vol. 18, No 3, 403-404, DOI: 10.11152/mu.2013.2066.183.kyk Corresponding author: Vincent Y.T. Cheung Department of Obstetrics and Gynaecology, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong Phone: 852-22553914, Fax: 852-25173278 E-mail:
[email protected]
Fig 1. Typical color Doppler ultrasound appearance of EMV/AVM as shown in one of our cases.
median diameter of the hypervascular lesionin our series was 2.0cm (range 1.0-3.2cm). The demographics and clinical outcomes are summarized in Table I. Notably all asymptomatic women had spontaneous resolution of the EMV/AVM with no abnormal bleeding. However, 2 women (15.4%) with abnormal bleeding remained symptomatic and ultimately required angiographic embolization. The median duration for sonographic resolution of the EMV/AVM was12weeks (range 2-52 weeks). Nowadays, color Doppler ultrasound is considered the primary diagnostic tool for women with suspected uterine EMV/AVM [2,3]. In most of our cases, the diagnosis of EMV/AVM was not confirmed angiographically and often, the diagnosis can be confused with retained products of gestation [4,5]. Therefore, without angiography, whether these ultrasound findings represent vascular retained products of gestation will never be certain. Nevertheless, clinicians need to advise women who present with this ultrasound finding. Despite the small number in our series which precludes us from drawing firm conclusions, our study suggests that most women with
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Management and outcome of sonographically diagnosed uterine enhanced myometrial vascularity
Table I. Demographics and clinical outcomes between women with and without abnormal bleeding
Age (year) Prior pregnancy event Spontaneous miscarriage Silent miscarriage, managed – Surgically – Medically – Medically + surgically Pregnancy termination and methods – Surgically – Medically Interval between pregnancy event and diagnosis of EMV/AVM in weeks (median, range) Size of EMV/AVM in cm (median, range) Progress during follow up No bleeding Persistent bleeding Bleeding resolved spontaneously Time to resolution of bleeding (for patients required no intervention, weeks) Time to resolution of EMV/AVM in weeks (median, range) Intervention Uterine artery embolization Blood Transfusion Defaulted follow up
Vaginal bleeding No (n=9) Yes (n=13) 32.1 +/- 5.4 31.1 +/- 6.7
p value^ 0.896
2 (22.2%) 6 (66.7%) 0 6 0 1 (11.1%) 1 0 1 (1-5)
1 (7.7%) 5 (38.5%) 3 1 1 7 (53.8%) 3 4 6 (0.4-12)
0.119 0.752
2.0 (1-2.7)
2.0 (1.1-3.2)
0.808
8 (88.9%) 0 1 (11.1%) not applicable 8 (4-52) [n=8]
0 2 (15.4%) 11 (84.6%) 0.3 - 3 [n=10] 12 (2-20) [n=10]
